A very positive development today, which I am pleased to say I had a hand in organising. 53 specialists in nicotine science and public health policy have written to Dr Margaret Chan, Director General of the WHO about tobacco harm reduction. The letter appeals for WHO to adopt a positive, proportionate and rational approach to products that provide very low-risk alternatives to smoking. In short, it calls on WHO to recognise this approach, tobacco harm reduction, is an important part of the solution offering great promise for public health, and not part of the problem.
I thought it would be good to have commentary on the text of the letter: so here is my ‘reader’s guide’. The letter text is picked out as quotes in boxes with a commentary beneath each section. Note: the commentary and interpretation are mine, and only the text is endorsed by the signatories.
Dr Margaret Chan
World Health Organisation
CC: FCTC Secretariat, Parties to the FCTC, WHO Regional Offices
The letter is addressed to the top people concerned with these issues at WHO.
- Dr Margaret Chan – Director General of the WHO
- Hail Nikogisian – Head of the Secretariat of the Framework Convention on Tobacco Control.
- Oleg Chestnov – Assistant Director General for Non-Communicable Diseases and Mental Health
- WHO Regional Offices – WHO’s regional network
- Parties to the FCTC – the 178 counties are Parties covering 90% of world’s population – the most notable exceptions are the United States and Switzerland.
Context: WHO Framework Convention on Tobacco Control
26 May 2014
Dear Dr Chan
Reducing the toll of death and disease from tobacco – tobacco harm reduction and the Framework Convention on Tobacco Control (FCTC)
We are writing in advance of important negotiations on tobacco policy later in the year at the FCTC Sixth Conference of the Parties. The work of WHO and the FCTC remains vital in reducing the intolerable toll of cancer, cardiovascular disease and respiratory illnesses caused by tobacco use. As WHO has stated, up to one billion preventable tobacco-related premature deaths are possible in the 21st Century. Such a toll of death, disease and misery demands that we are relentless in our search for all possible practical, ethical and lawful ways to reduce this burden.
The letter is about the ultimate aim of public health and the WHO – reducing the potentially massive toll of disease and preventable premature death through the use of very low risk alternatives to smoking and how the international treaty (Framework Convention on Tobacco Control) agreed in 2003 might apply to these harm reduction products. It refers to possible decisions that could be made at the Sixth Conference of the Parties ‘COP-6’ of the FCTC, which will be held in Moscow 13-18 August this year. This letter is intended to influence that process while those involved are still deciding what matters and what positions to adopt. The letter stresses ‘practical, ethical and lawful’ approaches, which is a particular strong point of ‘harm reduction’ approaches. Instead of requiring coercive, punitive or prohibitionist measures, harm reduction approaches go with the grain of people’s preferences.
Justification: basis for concern about approach of WHO
It is with concern therefore that a critical strategy appears to have been overlooked or even purposefully marginalised in preparations for FCTC COP-6. We refer to ‘tobacco harm reduction’ – the idea that the 1.3 billion people who currently smoke could do much less harm to their health if they consumed nicotine in low-risk, non-combustible form.
The ‘concern’ in question is a lightly stated and unconfrontational reference to several reasons to believe that WHO is institutionally hostile to harm reduction approaches. These include:
- The papers produced for COP-5 on Smokeless Tobacco and Electronic Nicotine Delivery Systems – see my Open letter to delegates to COP-5 challenging them on these issues from December 2102
- The leaked FCTC Bureau minutes of Nov 2013 describing how they wanted to class e-cigarettes as tobacco products (see para 23,72, and 69-75 especially) and my commentary WHO plans e-cigarette offensive
- The kind of presentations given by WHO staff in the European Parliament: the ‘F-grade presentation’ and the ‘Wisdom of WHO examined‘ being two examples
- Apparently supporting outright bans on e-cigarettes, for example in South East Asia in meetings where the implementation of FCTC is discussed
- The fact that WHO had gone out of its way to commission a literature review from academics hostile to harm reduction: Stanton Glantz and colleagues
Although it is Parties to the FCTC (i.e. national governments) that make the decisions, the role or secretariats and civil servants is often very influential. They draft papers, gather evidence, decide who speaks at meetings and who has access to the process etc. So it is important that they are taking a science and evidence-based approach as they will tend to set the direction and the Parties will tend to start with that and see what the need to change – in much the same way the European Commission (civil servants) makes proposals for legislation.
Introduction: the harm reduction case summarised
We have known for years that people ‘smoke for the nicotine, but die from the smoke’: the vast majority of the death and disease attributable to tobacco arises from inhalation of tar particles and toxic gases drawn into the lungs. There are now rapid developments in nicotine-based products that can effectively substitute for cigarettes but with very low risks. These include for example, e-cigarettes and other vapour products, low-nitrosamine smokeless tobacco such as snus, and other low-risk non-combustible nicotine or tobacco products that may become viable alternatives to smoking in the future. Taken together, these tobacco harm reduction products could play a significant role in meeting the 2025 UN non-communicable disease (NCD) objectives by driving down smoking prevalence and cigarette consumption. Indeed, it is hard to imagine major reductions in tobacco-related NCDs without the contribution of tobacco harm reduction. Even though most of us would prefer people to quit smoking and using nicotine altogether, experience suggests that many smokers cannot or choose not to give up nicotine and will continue to smoke if there is no safer alternative available that is acceptable to them.
We respectfully suggest that the following principles should underpin the public health approach to tobacco harm reduction, with global leadership from WHO:
This section sets out the well rehearsed ideas of a discontinuity of risk (not a risk continuum!) between products that involve combustion and those that do not. Significantly the authors did not restrict their definition to non-tobacco products such as e-cigarettes, but also non-combustible tobacco products such as snus and anticipated novel tobacco products. It frames the role of the these products in the context of targets set by the UN to reduce non-communicable diseases (NCDs) in 2011. Nine targets and 25 indicators have been set aiming to achieve by 2025 a headline 25% reduction in premature mortality from NCDs. To contribute to that, a target of a reduction of 30% in tobacco use by 2025 has been set. In the authors’ view, these targets can only realistically be met if harm reduction approaches are embraced, so that people can’t quit or don’t want to quit nicotine can live with much reduced risks to their health. The letter then sets out a series of ten principles for how harm reduction should be managed at global level.
Principle 1: harm reduction is part of the solution
1. Tobacco harm reduction is part of the solution, not part of the problem. It could make a significant contribution to reducing the global burden of non-communicable diseases caused by smoking, and do so much faster than conventional strategies. If regulators treat low-risk nicotine products as traditional tobacco products and seek to reduce their use without recognising their potential as low-risk alternatives to smoking, they are improperly defining them as part of the problem.
This is the overarching point – calling for a recognition that these products have great potential and that it is the job of WHO to help governments to exploit that potential, not to suppress it. The point about speed of response reflects the idea that people can switch their source of nicotine more rapidly and with less effort and willpower than if they have to quit nicotine completely: so it could be very fast-acting if the right products are on the market at the right price. We already know with certainty that a large number of people people have benefited personally from switching to e-cigarettes; that smoking prevalence is falling where e-cigarette use is rising; that where there is youth uptake of reduced risk products it is more than matched by declines in smoking; and that trials, surveys, sales data and user testimony all point in one clear and positive direction (whatever some activist researchers may say to the contrary).
We also know from the shameful experience of the snus ban in Europe, that arguments about hypothetical risks are made expediently to justify prohibitions well in advance of any evidence of harm. Many of the same arguments are now being used against e-cigarettes to justify excessive regulation, again without a shred of credible evidence of harm. Snus was banned in the EU (outside Sweden) in 1992. None of the hypothetical risks materialised in Sweden – snus was used to quit, and as an alternative to smoking. As it turns out, huge health benefits have emerged in Sweden (it has the lowest smoking prevalence by far and lowest levels of smoking related disease) but the opportunity for smokers elsewhere in Europe has been denied. Even when the evidence was crystal clear in showing a benefit to health, activists continued to campaign for the product to be banned. The EU, encouraged by prohibitionist activists, incorrectly defined snus as part of the problem. It is in fact part of the solution and that was clear at the time to anyone prepared to look. The new letter is urging WHO and the Parties to the FCTC not to make the same mistake, and to recognise that dramatic difference in risk of non-combustible nicotine products represents an opportunity.
Finally, we should step back and recognise just how bizarre and unprecedented it is to regard the emergence of products that are very much less risky than the market leader as an adverse development! I can think of no equivalents that are not equally bizarre (being opposed to condom use in areas of high risk of HIV/AIDS perhaps?). The world market for tobacco is $700-800 billion – it is an unambiguous, unequivocal good thing that much lower risk products are entering that market.
Principle 2: design a decent risk management framework
2. Tobacco harm reduction policies should be evidence-based and proportionate to risk, and give due weight to the significant reductions in risk that are achieved when a smoker switches to a low risk nicotine product. Regulation should be proportionate and balanced to exploit the considerable health opportunities, while managing residual risks. The architecture of the FCTC is not currently well suited to this purpose.
This states that a proper framework for managing risks is critical – and that this must recognise that ‘lost benefit’ is in itself a risk. The key feature of these products is that they substitute for smoking and provide much lower risk and this feature is far more important than their own residual risk, which is small or probably negligible. Yet almost everything written by WHO ignores this critical health benefit in the calculation of public health impact. The FCTC is an instrument designed with a quite single purpose: to reduce the use of tobacco in society and explicitly conflates this with reducing harm – it is coded into the very objective of the FCTC at Article 3.
The objective of this Convention and its protocols is to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke by providing a framework for tobacco control measures to be implemented by the Parties at the national, regional and international levels in order to reduce continually and substantially the prevalence of tobacco use and exposure to tobacco smoke.
Implicit in this statement is the idea that reducing tobacco consumption is always and everywhere synonymous with reducing harm. This is not always the case, as the experience of Sweden with snus shows, and it would be even more absurd if e-cigarettes and non-tobacco nicotine products were defined as tobacco products and brought under this regime. This is why the ‘architecture’ of the FCTC is not fit for managing harm reduction products. The danger of applying FCTC measures to other products that potentially reduce the harm cause by tobacco in society is obvious – a kind of double negative: reducing the use of products that reduce harm.
Principle 3: avoid unintentionally increasing cigarette consumption
3. On a precautionary basis, regulators should avoid support for measures that could have the perverse effect of prolonging cigarette consumption. Policies that are excessively restrictive or burdensome on lower risk products can have the unintended consequence of protecting cigarettes from competition from less hazardous alternatives, and cause harm as a result. Every policy related to low risk, non-combustible nicotine products should be assessed for this risk.
This develops theme of the second principle more aggressively – pointing out that many of the ‘tough’ regulations called for by some activists and legislators have a real and present danger that they will protect cigarettes from competition and support continued smoking. Some regulatory policies are clearly beneficial – they make for better quality products, mitigate health and safety risks and build consumer confidence – potentially increasing switching from cigarettes. But other more sweeping policies could do the opposite:
- Bans on advertising – removes ability of low risk products to build brands and communicate with consumers, to the benefit of incumbents (cigarettes)
- Broad prohibitions on flavours – makes for boring and bland products that reduce appeal to smokers, and increase likelihood that smokers will lose interest and relapse.
- Limits on nicotine strengths – makes it harder to make products that can compete in nicotine delivery with cigarettes
- Raising excise taxes – reduces the financial incentive to switch and therefore increases cigarette use
The reference to the precautionary principle is a reminder that this principle cuts both ways – in applying this principle you have to consider both risks and benefits or both intervention and non-intervention. Too often, the precautionary principle is invoked sloppily as a reason to take action where there is no supporting evidence. See a more developed discussion of the precautionary principle here.
Principle 4: don’t include harm reduction products in tobacco reduction targets
4. Targets and indicators for reduction of tobacco consumption should be aligned with the ultimate goal of reducing disease and premature death, not nicotine use per se, and therefore focus primarily on reducing smoking. In designing targets for the non-communicable disease (NCD) framework or emerging Sustainable Development Goals it would be counterproductive and potentially harmful to include reduction of low-risk nicotine products, such as e-cigarettes, within these targets: instead these products should have an important role in meeting the targets.
This arises from an apparent intention on the part of WHO to include e-cigarettes in targets to reduce tobacco consumption – a dangerously counterproductive idea. The concern arises from a consultation document on setting targets and indicators to replace the millennium development goals. In this document, WHO is shown to be pressing for e-cigarettes to be counted in a tobacco reduction target. On page 79 of the document it discusses indicator 47:
Rationale and definition: Tobacco use is a leading cause of preventable death in many developed countries, and is a growing problem and contributor to the burden of disease in developing countries. This indicator measures the prevalence of current smoking (daily, non-daily, or occasional) of any tobacco product, including cigarettes, cigars, pipes, etc., for adults aged 15 years and over. It expands upon the WHO’s recommendation to further track use of smokeless tobacco products (including chewing, snuff, and electronic cigarettes). The age-standardized prevalence rate of tobacco use (adjusted according to the WHO regression method) allows for comparisons across countries and across time periods to determine trends.  (emphasis added)
This is a logical consequence of defining e-cigarettes as a tobacco product under the FCTC – article 5 of FCTC includes an obligation to:
(b) adopt and implement effective legislative, executive, administrative and/or other measures and cooperate, as appropriate, with other Parties in developing appropriate policies for preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke
The much better approach is to use e-cigarettes, snus, and novel tobacco products to reduce smoking – and meet a meaningful target to reduce smoking. It is smoking that causes the vast bulk of the disease, and alternative to smoking that will reduce it most rapidly. Again, an undifferentiated approach to risk in setting targets will cause unintended negative consequences.
Principle 5: harm reduction approaches empower individuals
5. Tobacco harm reduction is strongly consistent with good public health policy and practice and it would be unethical and harmful to inhibit the option to switch to tobacco harm reduction products. As the WHO’s Ottawa Charter states: “Health promotion is the process of enabling people to increase control over, and to improve, their health”. Tobacco harm reduction allows people to control the risk associated with taking nicotine and to reduce it down to very low or negligible levels.
This makes the point that an important principle of public health is to empower people to control their own risks – and is a rejoinder to the ‘quit or die’ choice that many tobacco control activists believe will force the the pace of quitting. The 1986 Ottawa Charter is a powerful statement of the importance of individual empowerment. It is much better to give people the option to make good choices for their health – including reducing risk while continuing as a nicotine user – than to try to force them down a path that others regard as best for them.
Principle 6: counterproductive to ban advertising
6. It is counterproductive to ban the advertising of e-cigarettes and other low risk alternatives to smoking. The case for banning tobacco advertising rests on the great harm that smoking causes, but no such argument applies to e-cigarettes, for example, which are far more likely to reduce harm by reducing smoking. Controls on advertising to non-smokers, and particularly to young people are certainly justified, but a total ban would have many negative effects, including protection of the cigarette market and implicit support for tobacco companies. It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal. It is inappropriate to apply Article 13 of the FCTC (Tobacco advertising, promotion and sponsorship) to these products.
The market for cigarettes is $700-800 billion worldwide, and the market for e-cigarettes perhaps $5 billion in 2014. The challenge of low risk products is to erode the market for cigarettes as rapidly as possible and shift the market in recreational nicotine from harmful to relatively benign sources as rapidly as possible. From a public health perspective, it is a huge success when smokers switch to e-cigarette use or ‘vaping’ – almost the same as quitting completely. It is a success if the ‘buzz’ is with vaping and smoking feels and becomes outdated. To that end, edgy, sexy, fun advertising for vaping should be understood as a good thing for health. Advertising is also important in building brands and consumer confidence. Advertising is vital in communicating and rewarding innovation, which is especially important in a fast developing sunrise industry. Advertising is important in challenging incumbent industries (the cigarette market) by allowing disruptive upstarts to communicate with the incumbents’ customers. Even if these are tobacco companies, it is positive for health if BAT’s e-cigarette arm competes effectively for Philip Morris’s cigarette market and vice versa. Too much control or prohibition of advertising protects the incumbent products and vendors, while favouring those entrants with well developed retail distribution networks and experience of marketing without advertising: namely, the existing cigarette vendors. Article 13 of the FCTC applies to all tobacco products (including e-cigarettes if they were defined as tobacco products) and sets the expectation of a total ban (though allows exceptions where barred constitutionally:
13.2. Each Party shall, in accordance with its constitution or constitutional principles, undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. This shall include, subject to the legal environment and technical means available to that Party, a comprehensive ban on cross-border advertising, promotion and sponsorship originating from its territory.
The case for banning cigarette advertising rests on the 6 million annual deaths primarily from smoking. No such case can be made for banning products of much lower risk – in fact they are likely to have a negative death toll! A much better approach is to use the general principles for advertising (“legal decent honest truthful“) with additional safeguards – perhaps similar to those used for alcohol advertising. UK Committee of Advertising Practice has consulted on proportionate controls like these: here is my response and the response from Action on Smoking and Health – both broadly supportive with different emphases.
Principle 7. Use of vapour products in public places
7. It is inappropriate to apply legislation designed to protect bystanders or workers from tobacco smoke to vapour products. There is no evidence at present of material risk to health from vapour emitted from e-cigarettes. Decisions on whether it is permitted or banned in a particular space should rest with the owners or operators of public spaces, who can take a wide range of factors into account. Article 8 of the FCTC (Protection from exposure to tobacco smoke) should not be applied to these products at this time.
The basis of this principle is that the force of law should be reserved for regulation of harms or material risk to people not using e-cigarettes – workers or bystanders – otherwise the owners or operators of public places should decide their policy. But that etiquette, good taste, smells and aesthetics should not be regulated by law, but determined by the owners or operators of public premises taking a broader range of factors into account. The ethical argument is that the coercive powers of law should be used only where there is a harmful ‘externality’ – or at least a good case to expect one. The principle is not intended to create a right to use an e-cigarette, but to determine who decides – the law or the owner. Generally we would expect most places to ban the use of e-cigarettes by default. But should owners really be required by law to do this if they would otherwise choose not to? In the situation where a bar owner, for example, wishes to allow vaping, or a cafe or hospital wishes to have a vaping area, or a vapour shop or club wants to allow it, why should the law stop them unless there is material risk to others? They may have many factors to take into account – social, economic, and health – and decide that it is better to permit it. There may be benefits to health in allowing it some situations (for example where it is important to help smokers stay off cigarettes), and it may add to the incentive for smokers to switch creating additional health benefits. It should not be argued that a ban is a ‘no regrets’ option – there needs to be a justification.
In the UK smokefree legislation exists to protect the public from the demonstrable harms of secondhand smoke. ASH does not consider it appropriate for electronic cigarettes to be subject to this legislation, but that it should be for organisations to determine on a voluntary basis how these products should be used on their premises
8 Protection from exposure to tobacco smoke
1. Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability.
2. Each Party shall adopt and implement in areas of existing national jurisdiction as determined by national law and actively promote at other jurisdictional levels the adoption and implementation of effective legislative, executive, administrative and/or other measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.
Principle 8: Taxation
8. The tax regime for nicotine products should reflect risk and be organised to create incentives for users to switch from smoking to low risk harm reduction products. Excessive taxation of low risk products relative to combustible tobacco deters smokers from switching and will cause more smoking and harm than there otherwise would be.
This is a statement of economic reality. It reflects the role that price plays as an incentive to switch, to quit, to seek black market products or to continue smoking. It is therefore an area where careful design of the taxation regime is necessary if it is not going to support healthy choices on not have unwanted adverse effects on health. It may be particularly important in reaching poorer smokers and hence being an important countermeasure to health inequalities. There is a higher proportion of smokers in poorer socio-economic groups and poorer smokers tend to be more highly dependent and have lower success rates at quitting. It should be argued on principle that the policy of raising taxes on cigarettes, an addictive product, is regressive (costs fall disproportionately on low income groups) and punitive (if it falls on people who cannot or will not quit smoking). The most important mitigating measure for these negative aspects of taxation is the availability of a credible alternative, to which committed or addicted nicotine users can switch. Though not addressed in the letter, I do not think it makes any sense to subsidise e-cigarettes, either through a lower rate of VAT or through funding through the health care system – all that means is that others (non-users) are paying through the tax system instead of the user.
Principle 9. Use of evidence
9. WHO and national governments should take a dispassionate view of scientific arguments, and not accept or promote flawed media or activist misinterpretations of data. For example, much has been made of ‘gateway effects’, in which use of low-risk products would, it is claimed, lead to use of high-risk smoked products. We are unaware of any credible evidence that supports this conjecture. Indeed, similar arguments have been made about the use of smokeless tobacco in Scandinavia but the evidence is now clear that this product has made a significant contribution to reducing both smoking rates and tobacco-related disease, particularly among males.
This reflects mounting dismay among serious sober experts at the way scientific findings are being contrived or spun to draw hostile conclusions regarding e-cigarettes. My own contribution to highlighting and challenging this academic malpractice is a ‘Cease and Desist’ letter to Professor Stanton Glantz regarding ridiculous assertion and hype about adolescent e-cigarette use. There isn’t enough space to capture all the poor quality argument and hype created by so-called experts: but I recommend the following three as the most vigilant challenge to academic bias and outright perversion of the scientific process.
Sadly, the established peer review process does not appear to mount an equivalent or adequate challenge, and several journals seem to be developing biases against e-cigarettes. There is particular concern about institutions like WHO seeking scientific advice from sources they know are sympathetic to a particular policy conclusion: so-called policy-based evidence-making. This appears to be the case in the commission of Professor Glantz’s group to provide a literature review on e-cigarettes: Background paper on e-cigarettes (Electronic Nicotine Delivery Systems). Although some of the analysis in the bulk of the document is adequate, the executive summary is a masterpiece of manipulative half-truths, non- sequiturs and inappropriate emphasis. As if to illustrate my point about the shoddiness of the peer review system, a summary of this has found its way into the journal ‘Circulation’ – a publication whose editors and readership are more usually concerned with blood. The danger is that a respectable journal has been chosen as a soft target for publishing an article in which it has no specialisation. I hope there will be a response to this shortly.
Principle 10: take sound scientific advice
10. WHO and parties to the FCTC need credible objective scientific and policy assessments with an international perspective. The WHO Study Group on Tobacco Product Regulation (TobReg) produced a series of high quality expert reports between 2005 and 2010. This committee should be constituted with world-class experts and tasked to provide further high-grade independent advice to the WHO and Parties on the issues raised above.
This recognises the excellent work of the TobReg group when it was in its productive prime between 2005 and 2001. A series of reports from this advisory group properly recognised the issues of relative risk and made recommendation for regulatory responses that would allow for harm reduction, whilst mitigating risks. The aim of the group is to provide top quality advice to WHO and the the parties to the FCTC. It has however in recent years become less influential and appears to have been downgraded by WHO in favour of working groups of member state representatives. The two are not incompatible, and it is a false economy to take other than the best scientific advice from a diverse group of the most accomplished scientists and experts.
The potential for tobacco harm reduction products to reduce the burden of smoking related disease is very large, and these products could be among the most significant health innovations of the 21st Century – perhaps saving hundreds of millions of lives. The urge to control and suppress them as tobacco products should be resisted and instead regulation that is fit for purpose and designed to realise the potential should be championed by WHO. We are deeply concerned that the classification of these products as tobacco and their inclusion in the FCTC will do more harm than good, and obstruct efforts to meet the targets to reduce non-communicable disease we are all committed to. We hope that under your leadership, the WHO and FCTC will be in the vanguard of science-based, effective and ethical tobacco policy, embracing tobacco harm reduction.
We would be grateful for your considered reaction to these proposals, and we would like to request a meeting with you and relevant staff and a small delegation of signatories to this letter. This statement and any related information will be available on the Nicotine Science and Policy web site (http://nicotinepolicy.net) from 29 May 2014.
This section states the opportunity and the main concern that WHO will blow it. That is that the apparent intent of WHO to classify e-cigarettes as tobacco products and thereby to treat them in an undifferentiated way to cigarettes will end up causing more harm than good, and will mea an opportunity to meet the UN targets will be squandered. Of course the concern remains with products that are tobacco, like snus or novel non-combustion tobacco products, but potentially very beneficial to health as alternatives to smoking. To address this issue within the tobacco category, the FCTC would need to become much more sensitive to relative risk than it is now. The letter was sent a few days in advance of publication as a courtesy and to allow WHO to make a considered response. I hope they will take time to reflect and accept the request for a meeting with Dr Chan.
List of signatories
You can see a full list at the bottom of the letter (not repeated here). In my view, these are among the most credible experts in the field. Many feel strongly that the ‘risk politics’ of public health has gone awry and what used to be an overriding priority to tackle smoking related cancer, cardiovascular disease and lung ailments has become a dogmatic fight against nicotine use, the tobacco industry or anything that resembles smoking – to the likely detriment of health. People who vape or use snus should not see ‘public health’ as their enemy – it is much more complicated than that. If there is a split in public health, it is best characterised as between experts and activists – with experts supportive of harm reduction and activists instinctively hostile, and with notable exceptions on each side.
Any questions, disagreements or requests for more information – let me know in the comments.